Dental Clues to Medical Conditions

Bad Breath

Not only is understanding dental health important for correctional nurses as front-line healthcare providers in screening, sick call, and emergencies, but the mouth can provide clues to many medical conditions and drug side effects. Here are some of the most common conditions that can yield clues during an oral exam.

Anemia

Lack of hemoglobin can cause pallor of the oral tissues but this is often difficult to distinguish. More telling is glossitis, which is a smooth, reddened, sometimes patchy tongue surface. Anemia can also lead to burning, pain, or tenderness of the oral mucosa. Oral candidiasis, a yeast infection involving small, curdy-appearing white papules and plaques, can develop due to decreased immune system function in chronic anemia.

Bulimia

Excessive dental erosion in young females could be an indication of bulimia. Exposure of the teeth to the high acid content of gastric contents with forced vomiting causes erosion of the lingual (tongue-side) surface. Bilateral enlarged parotid glands are also seen frequently in bulimia.

Diabetes

A variety of oral conditions arise from diabetes and should be considers as clues to the disease. The increased blood sugar levels of untreated or under-treated diabetes leads to tooth decay, gingivitis, and periodontal infection. In addition, nerve and vascular complications of the condition reduce saliva production and slow the normal healing process.

An interesting finding is that poor dental hygiene can also exacerbate diabetes. Treatment of dental conditions has been found to improve blood sugar control in diabetics. Therefore, good oral health should be a part of diabetic education and chronic care monitoring for patients with this disease.

HIV Infection

Oral manifestations may be the first indication of HIV infection.  Immunosuppression from HIV disease leads to oral candidiasis in 90% of those with HIV. Herpes simplex is another common oral infection frequently contracted by individuals with HIV. Other oral infections include hairy leukoplakia, Kaposi Sarcoma, and HPV infection.

Leukemia

Leukemia can lead to oral bleeding, inflammation, and ulceration. The impaired immune function of leukemia can also lead to mouth infections such as candidiasis and herpes simplex.

Medication Side Effects

Medication use can also have oral effects worth noting on assessment. Here are a few of the most common oral conditions caused by medications.

  • Dry mouth (xerostomia) is the most frequent oral side effect of medications and can lead to increased risk of infection and decay. Diuretics and antidepressants are common culprits of dry mouth.
  • Inhaled Steroids used by asthmatics can cause candidiasis.
  • Hyperplasia, overgrowth of the gums, can be a side effect of phenytoin, calcium channel blockers, and cyclosporine.

If any of these medical conditions are encountered during an oral screening, carefully document your findings, initiate appropriate treatment, and communicate this information to medical or dental providers for a diagnostic work-up.

Resources for This Post

Common Oral Manifestations of Systemic Disease- PubMed

Oral Manifestations of Systemic Disease – American Family Physician

Oral Manifestations of Systemic Disease – Medscape

Have you discovered a medical condition during one of your oral exams? Share your experiences in the comments section of this post.

Read more about dental issues for correctional nurses in Chapter 7: Dental Conditions from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

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Dental Triage: What is an Emergency?

Toothache - man with teeth problems

Correctional nurses regularly make decisions about the need for emergency treatment of dental conditions. These decisions come as a part of dealing with a sick call request or a ‘man down’ in the facility. What are some key findings that indicate a need for emergency dental treatment?

Breathing and Swallowing

Emergency evaluation starts with the ABC’s (Airway-Breathing-Circulation). Dental conditions affect the ability to breathe and swallow. These are two immediate concerns in evaluating any dental condition. Ability to breathe and swallow is affected by infection, traumatic injury, persistent bleeding in the oral cavity, or swelling. Impairment of breathing or swallowing needs immediate emergency treatment.

Pain

Tooth pain is probably the most frequent dental condition correctional nurses  evaluate. Nurses must make an assessment to determine if the pain requires immediate attention or can wait for the next dental opening. A proper dental pain assessment includes the following components:

  • Assess the pain using the pain scale (1 -10)
  • Determine what incites the pain: thermal sensitivity (cold vs hot), biting pressure, constant pain, recent dental procedure.
  • Have the patient describe the pain: continuous, intermittent, transient
  • Have the patient locate the pain by pointing to the tooth or area of the mouth. Sometimes the pain can be referred by an adjacent tooth or come from the opposite arch.
  • Check the tissue for swelling. Check to see if the tooth is fractured. This helps to determine if the pain is from the soft tissue or from the tooth itself.

Often the overall condition of the patient can indicate the intensity of the pain and the level of treatment need. Obviously a toothache that has kept a patient up all night due to unremitting pain needs to be seen by the dentist immediately.  Patients that are having  intermittent pain or occasionally occurring pain can usually be given pain meds and appointed to the dental office at the next available opening.

Infection

Severe infections, like severe pain, will affect the entire patient. Vital signs and general appearance will be altered. If the patient has facial swelling, a pulse greater than 100 and a temperature over 101 F, they need to see a dentist immediately. This may indicate a systemic infection or cellulitis that requires aggressive antibiotic treatment.

Indications of a milder mouth infection can be treated with over-the-counter pain medication and be scheduled for a dental or medical staff appointment in the next 24 hours. Mild infection presents as localized swelling and a fever of less than 101 F. Supportive care such as a soft diet and heat application may also help.

Have you had to deal with a challenging dental emergency? Share your experiences in the comments section of this post.

Read more about dental issues for correctional nurses in Chapter 7: Dental Conditions  from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

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Dental Assessment at Intake

Checking Throat

He came into the jail on a charge of petty larceny but his dental condition was the real crime. Years of methamphetamine use and oral hygiene neglect resulted in missing teeth and severe decay. What does a nurse look for during intake dental screening?

Nurses are the healthcare professional most frequently performing health screening during intake and booking. Since the initial screening is meant to reveal the need for immediate attention, nurses must know what findings indicate urgent concern. A systematic process for dental screening will direct appropriate attention to areas of need.

Subjective

A person’s medical and dental history hold clues to potential dental issues that need attention. The following questions can reveal pertinent background for a complete dental profile.

  • Are you currently undergoing a dental procedure or receiving dental treatment?
  • Have you been hospitalized recently?
  • What medications are you currently taking?
  • Do you have any dental concerns?
  • Do you have any removable dental appliances such as dentures, partial dentures, or bridges?

Objective

Developing oral assessment skills will help in determining conditions that need a dentist’s attention. Focus on learning what normal looks like. Then, abnormalities will clearly present themselves.

  • Lips and buccal mucosa should be pink, soft, moist and smooth. Note any pallor, cyanosis or blistering
  • Teeth should be white and smooth. Note any missing teeth or ill-fitting dentures
  • Gums should be moist and firm without retraction. Note any receding or bleeding gums
  • Tongue should be pink, move freely, and without tenderness
  • Floor of mouth should be smooth and without mass or lesion
  • Palate and oropharynx should be pink and smooth. Note any discolorations, swelling, or boney growths.

Special Issues

Trauma: Recent mouth trauma might be present due to the circumstances of arrest. Note any lost or broken teeth. In addition, consider fractures of the jaw or other facial structures in your examination. Facial or oral trauma may result in airway obstruction and should be closely managed.

Infection: Infection is always an area of concern. A significant mouth infection that results in facial swelling, temp greater than 101 F and an elevated pulse over 100 bpm indicates a need for immediate provider attention. Localized swelling with fever less than 100 F and no difficulty swallowing can be seen by a provider in the next 24 hours.

Oral Cancers: Oral cancers are high among tobacco and alcohol users. Therefore, inmate-patients are prime candidates for the condition. Mouth lesions should be referred to a dentist when they are red with diffuse borders, white patches that don’t rub off, or a lump or numbness. In addition, hoarseness and difficulty chewing or swallowing can be indications of oral cancer.

Devices: Cataloging all tooth equipment on intake is an important nursing function.  This helps validate patient information later in the stay. For example, a patient might contend that a dental partial plate was taken from them during a cell sweep. This could be an expensive replacement. However, careful documentation on intake might reveal that the patient did not enter the facility with their partial.

What have you discovered about dental assessment as a correctional nurse? Share your experiences in the comments section of this post.

Read more about dental issues for correctional nurses in Chapter 7: Dental Conditions  from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

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I Didn’t Sign Up For This! Dental Issues for Correctional Nurses

a young man with a toothache on white background

One of the first things I discovered when I started in corrections was the importance of teeth. Frankly, I did not think much about these handy items while in nursing school and, working in critical care and orthopaedics before going behind bars, I didn’t have much opportunity to consider them. In addition, my patient population was generally middle-class and affluent, in comparison to my correctional patient population. Needless to say, I had a fiery baptism into the crazy world of dental issues.

Why are dental conditions a concern for correctional nurses? First of all, nurses end up being the first person an inmate sees about a dental concern. This is usually at a receiving screening or through the nursing sick call process. So, nurses must be able to determine the nature of the issue and make a decision about urgency of treatment. A dental episode might be remedied with instruction on self-treatment, may need assignment to the next available dental appointment, may need urgent evaluation by a dentist, or may need emergency treatment in the acute care setting. It requires significant clinical judgment abilities to appropriately manage dental issues.

Another reason dental conditions are a concern for correctional nurses is because there are so many of them in our patient population. Our patients are less likely to have received dental care in the past and many have a lifestyle that does not include high levels of dental hygiene. Therefore dental decay and periodontal disease are seen frequently. Our patients come from violent backgrounds that can result in tooth trauma. They also indulge in high levels of alcohol, tobacco, and drug use. All these substances have a negative effect on dental health.  Methamphetamine use, in particular, can cause severe dental erosion and decay. Self-medicating with alcohol and drugs can mask tooth pain. Once incarcerated and withdrawn from these substance, inmates feel increasing mouth pain that leads to dental requests for evaluation and treatment.

Finally, systemic chronic conditions and infections affect dental health. Nurses who understand the relationship of dental conditions to systemic disease can often activate medical evaluation when a dental manifestation is observed. For example, canker sores or herpes can appear on the mouth of an immunosuppressed individual and periodontal infection can exacerbate blood glucose levels in diabetics.

What have you discovered about dental conditions as a correctional nurse? Share your experiences in the comments section of this post.

Read more about dental issues for correctional nurses in Chapter 7: Dental Conditions  from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

Photo Credit: © vladimirfloyd – Fotolia.com